E-DRUG: Training Adherence support workers
[Adherence to chronic medication is a known problem, and many efforts have
been tried to motivate patients to adhere to their protocols. Here an
interesting story from Zambia.
Copied with thanks as fair use from:
A CDROM exists with all materials.
All training materials (the 230-page facilitator guide, promotional
materials and participants' guides etc) on adherence training can be freely
downloaded from: http://www.fhi.org/en/HIVAIDS/pub/res_ASW_CD.htm
Adherence Support Workers Fill Gaps and Help to Close a Circle
AUGUST 2007 - When USAID informed staff of the Zambia Prevention, Care and
Treatment Partnership (ZPCT) in 2005 that supplemental funding from the
Office of the US Global AIDS Coordinator might be available to the project,
there was no debate about the best use for the funds. Everyone agreed that
the most urgent need was to address the critical shortage of healthcare
workers by training community volunteers to help patients on antiretroviral
drugs adhere to treatment, thus relieving overworked clinical staff. This
was the best way to advance the mission of this FHI-managed, six-year
collaboration between the Republic of Zambia and the US Government-to
strengthen and expand HIV and AIDS services in five provinces.
The funding allocated enabled the project to train and deploy volunteer
adherence support workers (ASWs) at all health facilities where ZPCT
supports antiretroviral treatment services-a total of 52 facilities, as of
Staff from the ZPCT Technical Services Division and FHI's Care and Treatment
Division (CTD) developed training materials, worked out details of the
program, and supported the training courses, including participants'
transportation and meals, working in partnership with Zambia's Ministry of
Health at national, provincial, district, and facility levels.
A transformative training program
ZPCT staff jumped at the chance to work on training materials that would be
needed. They knew that the ASWs would become a critical component of
HIV/AIDS care and prevention if they were seen as vital members of
multidisciplinary HIV teams within the health facilities, and if the ASWs
received tailor-made and appropriate training. The buy-in of medical staff
was essential to the program's success, since ASWs would report to a nurse
at each facility and participate in clinical meetings.
And ZPCT staff also knew that trained ASWs would do more than support their
clients' adherence to treatment. If the ASWs were based within the health
facilities and integrated into their staff, this would facilitate crucial
connections between the facilities and the communities where the ASWs lived.
The ASW training program might become transformative: it promised to foster
a single, expanded circle of care and treatment, rather than adding a loop
of home-based, community care that would be a satellite or appendage of the
health facility. And, because people living with AIDS (PLHA) were the
priority for recruitment as ASWs, the program stood to cement other,
important connections by giving PLHA a vital and rewarding role in the
day-to-day operations of the health facilities.
The training, in practice
The training course, developed collaboratively by ZPCT and CTD staff,
reflected these objectives. As well as providing a wealth of information on
counseling and communication and on HIV and AIDS care and treatment, course
materials helped ASWs participate in referral networks; work alongside
nurses and doctors as part of a clinical team; and interact with patients in
clinical, community, and home settings. Participatory methodologies,
practical hands-on approaches, role plays, exercises, and small-group
discussions were built into the course materials to help attain these
Staff of the health facilities selected candidates for this training, and
none had trouble doing so. Up to four ASWs would be deployed in each
facility-all were PLHA, and nearly all were on antiretroviral therapy.
A questionnaire ascertains how much candidates for training know before the
course starts. Participants are also tested at the end of their training,
which is delivered by experienced facilitators and clinical staff. During
the course, trainees visit nearby health facilities, and they return to
their home facilities for practicums. Each training graduate receives a
certificate and a badge.
The ASW's work and accomplishments
On their return to their home facilities, ASWs work in rotation, each about
20 hours a week. They spend two days in a health facility and the third day
in a nearby community, where they visit patients to support their adherence
to treatment and track down treatment defaulters and try to re-engage them.
To facilitate this work, ZPCT has purchased one or two bicycles per health
facility for the ASWs to share.
The ASWs are volunteers-the only payment they receive is a transportation
stipend, which amounts to 100,000 kwacha (about US$25) per month. These
payments are arranged through subagreements with district health
authorities, not directly with the health facilities.
The ASWs provide extraordinary value for these modest expenditures.
According to one report, they have relieved a considerable burden from
homecare workers, and they have become "absolutely critical to facilities'
ability to maintain increasing numbers of treatment clients and track
And most ASWs put in more than the required 20 hours; they are committed to
the work and find it extremely gratifying. Their clients often share
concerns or describe symptoms that they haven't yet disclosed to medical
staff. And the ASWs realize that their contributions-in a patient's own
language and rooted in local culture-improve patient adherence, knowledge,
Expanding beyond Zambia
As of June 30, 224 ASWs have graduated from the course in Zambia. A draft
version of the training guide has been used in Kano, Nigeria, and FHII's
Global HIV/AIDS Initiative Nigeria (GHAIN) is planning to hold a series of
trainings to develop a cadre of ASWs at GHAIN-supported sites.
Those who want to pursue this innovative training program do not need to
wait for a mail delivery: all the materials can be accessed here, at the
click of a button, with no waiting for downloads!
- Hilary Russell
C Copyright 2007, Family Health International (FHI)